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• PTSD QUARTERLY
  Published by:National Center for PTSDVA Medical Center (116D)215 North Main StreetWhite River JunctionVermont 05009-0001 USA
  (802) 296-5132FAX (802) 296-5135Email: ncptsd@va.gov
  All issues of the PTSD Research Quarterly are available online at: www.ptsd.va.gov

  Military personnel serving in war are confronted with ethical and moral challenges, most of which are navigated successfully because of effective rules of engagement, training, leadership, and the purposefulness and coherence that arise in cohesive units during and after various challenges. However, even in optimal operational contexts, some combat and operational experiences can inevitably transgress deeply held beliefs that undergird a service members humanity. Transgressions can arise from individual acts of commission or omission, the behavior of others, or by bearing witness to intense human suffering or the grotesque aftermath of battle. An act of serious transgression that leads to serious inner conflict because the experience is at odds with core ethical and moral beliefs is called moral injury. More specifically, moral injury has been defined as perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations (Litz et al., 2009). Various acts of commission or omission may set the stage for the development of moral injury. Betrayal on either a personal or an organizational level can also act as a precipitant. On a conceptual level, moral injury is different from long-established post-deployment mental health problems. For example, whereas PTSD is a mental disorder that requires a diagnosis, moral injury is a dimensional problem. There is no threshold for establishing the presence of moral injury; rather, at a given point in time, a Veteran may have none, or have mild to extreme manifestations. Furthermore, transgression is not necessary for a PTSD diagnosis nor does PTSD sufficiently capture moral injury, or the shame, guilt, and self-handicapping behaviors that often accompany moral injury.
  Although the idea that war can be morally compromising is not new, empirical research about moral injury is in its infancy, and there are more unanswered questions than definitive answers at this point. Below we review key studies that fall under the umbrella of moral injury, noting the limitations of current knowledge and suggesting future research directions.
  For those interested in learning more about the topic of moral injury, Litz et al. (2009) provide a comprehensive review, complete with working definitions, prior research in related areas, a preliminary conceptual model, and intervention suggestions. The conceptual model posits that individuals who struggle with transgressions of moral, spiritual, or religious beliefs are haunted by dissonance and internal conflicts. In this framework, harmful beliefs and attributions cause guilt, shame, and self-condemnation. Forgiveness is also an important mediator of outcome. The moral injury framework posed by Litz et al. suggests that although moral injury is manifested as PTSD-like symptoms (e.g., intrusions, avoidance, numbing), other outcomes are unique and include shame, guilt, demoralization, self-handicapping behaviors (e.g., self-sabotaging relationships), and self-harm (e.g., parasuicidal behaviors). This framework highlights the importance of thinking in a multi- or inter-disciplinary fashion about helping repair the moral wounds of war. Litz et al. argue that existing PTSD treatment frameworks may not sufficiently target moral injury.
  As a first step to validating the construct of moral injury, Drescher et al. (2011) conducted interviews with a diverse group of health and religious professionals who work with active-duty
  
  military personnel and Veterans in order to better categorize war-zone events that may contribute to moral injury. Emerging themes included betrayal (e.g., leadership failures, betrayal by peers, failure to live up to ones own moral standards, betrayal by trusted civilians), disproportionate violence (e.g., mistreatment of enemy combatants and acts of revenge), incidents involving civilians (e.g., destruction of civilian property and assault), and within-rank violence (e.g., military sexual trauma, friendly fire, and fragging). The authors suggest that an important next step would be to directly interview Veterans about their experiences to help expand this list.
  The authors also interviewed providers about signs or symptoms of moral injury, and the results of this inquiry fit nicely with the aspects of the model described in Litz et al. (2009): social problems, trust issues, spiritual/existential issues, psychological symptoms, and self-deprecation. Study participants also made important suggestions about ways to repair moral injury; these can be categorized into spiritually directed, socially directed, and individually directed interventions. This last point emphasizes that in addition to traditional individual-based therapies, interventions for moral injury should be considered across multiple disciplines (e.g., involving spiritual leaders), and that collaborative work across multiple systems may lead to the best results (i.e., multidisciplinary effort that also considers social systems in which the individual is based and can receive help and support).
  A number of studies have empirically demonstrated the potential moral injuries of war. For example, several articles have documented the relationship between killing in war and a number of adverse outcomes. Fontana & Rosenheck (1999) found that killing and injuring others was associated for PTSD even when accounting for other exposures to combat within a larger model. Subsequent studies have expanded upon these findings, demonstrating a relationship between killing and a host of other mental health and functioning variables. In Vietnam Veterans, after controlling for exposure to general combat experiences, killing was associated with posttraumatic stress disorder symptoms, dissociation, functional impairment, and violent behaviors (Maguen et al., 2009). Furthermore, the association with each outcome was stronger among those who reported killing non-combatants. In returning OIF Veterans, even after controlling for combat exposure, Maguen et al. (2010) found that taking another life was a significant predictor of PTSD symptoms, alcohol abuse, anger, and relationship problems. In Gulf War Veterans, killing was a significant predictor of posttraumatic stress symptoms, frequency and quantity of alcohol use, and problem alcohol use, even after statistical control for perceived danger, exposure to death and dying, and witnessing killing of fellow soldiers (Maguen, Vogt et al., 2011).
  Beckham and colleagues (1998) focused on exposure to atrocities and found that after controlling for general combat, atrocities were associated with PTSD symptoms, guilt, and maladaptive cognitions. Marx et al. (2010) found that combat-related guilt mediated the association between participation in abusive violence and both PTSD and MDD. In analyses to further explore which components of PTSD were most important, Beckham and colleagues (1998) demonstrated that the strongest association between atrocities and PTSD was with the re-experiencing cluster. Other studies have also found that atrocities are most associated with re-experiencing and avoidance, rather than with hyperarousal symptoms of PTSD, which follows logically given
  that morally injurious events are more guilt- and shame-based than fear-based. Taken as a whole, this body of research suggests that morally injurious acts such as killing and atrocities are associated not only with PTSD (particularly re-experiencing and avoidance, rather than hyperarousal), but also with a host of other mental health problems and debilitating outcomes.
  The link between guilt and suicide, a putative outcome stemming from moral injury, is also an important area of inquiry. Fontana et al. (1992) highlighted how different trauma types can lead to diverse mental health and functional outcomes. They found that being the target of killing or injuring in war was associated with PTSD and being the agent of killing or failing to prevent death or injury was associated with general psychological distress and suicide attempts. In a related study, Hendin and Haas (1991) found that combat guilt was the most significant predictor of both suicide attempts and preoccupation with suicide, suggesting that guilt may be an important mediator. The authors also reported that for a significant percentage of the suicidal Veterans, the killing of women and children occurred while feeling emotionally out of control due to fear or rage. This suggests that killing of women and childrenarguably morally injurious eventsmay be associated with guilt feelings. A more recent study of service members who have recently returned from war suggests that the relationship between killing and suicide may be mediated by PTSD and depression (Maguen, Luxton et al., 2011).
  The Interpersonal-Psychological Theory of Suicide (reviewed by Selby et al., 2010) offers an important backdrop within which to digest some of these findings. The theory also fits well with the model of moral injury. According to the theory, three factors are associated with suicide: feelings that one does not belong with other people, feelings that one is a burden on others or society, and an acquired capability to overcome the fear and pain associated with suicide. The authors suggest that of all factors, acquired capability may be the most associated with military experience because combat exposure and training may cause habituation to fear of painful experiences, including suicide. Consequently, killing behaviors, through a series of other mediators, result in more easily being able to turn the weapon of destruction onto oneself. Interestingly, findings from Killgore at al. (2008) suggest that suicide is not the only high-risk outcome of concern; indeed a variety of arguably morally injurious combat actions can lead to multiple risky behaviors. More specifically, greater exposure to violent combat, killing another person, and contact with high levels of human trauma were associated with greater post-deployment risk-taking in a number of different domains.
  There is also a series of articles that point to important potential mediators within the context of moral injury. Beckham and colleagues (1998) highlighted the role of cognitions related to hindsight bias and wrongdoing among those endorsing atrocities. Witvliet et al. (2004) examined forgiveness of self and others and found that difficulty with any kind of forgiveness was associated with PTSD and depression and that difficulty with self-forgiveness was associated with anxiety. Religious coping seemed to be associated with PTSD symptoms but the authors cautioned that this relationship should be explored in greater detail. Indeed, this and other studies have highlighted that the religious and spiritual causes and consequences of moral injury are complex and need to be explored. For example, many of the pre-existing morals and values that are transgressed in war stem from religious beliefs and faith practices. Religion and spirituality are critical components VOLUME 23/NO. 1 2012 PAGE 3
  
  preliminary effectiveness of a novel intervention that was developed to address combat stress injuries in active-duty military personnel. Adaptive disclosure (AD) is relatively brief to accommodate the busy schedules of active-duty service members while training for future deployments. Further, AD takes into account unique aspects of the phenomenology of military service in war in order to address difficulties such as moral injury and traumatic loss that may not receive adequate and explicit attention by conventional treatments that primarily address fear-inducing life-threatening experiences and sequelae. In this program development and evaluation open trial, 44 marines received AD while in garrison. It was well tolerated and, despite the brief treatment duration, promoted significant reductions in PTSD, depression, and negative posttraumatic appraisals, and was also associated with increases in posttraumatic growth.
  Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., et al. (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29, 695-706. doi: 10.1016/j.cpr.2009.07.003. Throughout history, warriors have been confronted with moral and ethical challenges, and modern unconventional and guerrilla wars amplify these challenges. Potentially morally injurious events, such as perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations may be deleterious in the long-term, emotionally, psychologically, behaviorally, spiritually, and socially (what we label as moral injury). Although there has been some research on the consequences of unnecessary acts of violence in war zones, the lasting impact of morally injurious experience in war remains chiefly unaddressed. To stimulate a critical examination of moral injury, we review the available literature, define terms, and offer a working conceptual framework and a set of intervention strategies designed to repair moral injury.
  Maguen, S., Lucenko, B. A., Reger, M. A., Gahm, G. A., Litz, B. T., Seal, K. H., et al. (2010). The impact of reported direct and indirect killing on mental health symptoms in Iraq War veterans. Journal of Traumatic Stress, 23, 86-90. doi: 10.1002/jts.20434. This study examined the mental health impact of reported direct and indirect killing among 2,797 U.S. soldiers returning from Operation Iraqi Freedom. Data were collected as part of a postdeployment screening program at a large Army medical facility. Overall, 40% of soldiers reported killing or being responsible for killing during their deployment. Even after controlling for combat exposure, killing was a significant predictor of PTSD symptoms, alcohol abuse, anger, and relationship problems. Military personnel returning from modern deployments are at risk of adverse mental health conditions and related psychosocial functioning related to killing in war. Mental health assessment and treatment should address reactions to killing to optimize readjustment following deployment.
  Maguen, S., Luxton, D. D., Skopp, N. A., Gahm, G. A., Reger, M. A., Metzler, T. J., et al. (2011). Killing in combat, mental health symptoms, and suicidal ideation in Iraq War Veterans. Journal of Anxiety Disorders, 25, 563-567. doi: 10.1016/j.janxdis.2011.01.003. This study examined combat and mental health as risk factors of suicidal ideation among 2,854 U.S. soldiers returning from deployment in support of Operation Iraqi Freedom. Data were collected as part of a postdeployment screening program at a large Army medical facility. Overall, 2.8% of soldiers reported suicidal ideation. Postdeployment depression symptoms were associated with suicidal thoughts, while postdeployment PTSD symptoms were associated with current desire for self-harm. Postdeployment depression and PTSD symptoms mediated the association between killing in combat and suicidal thinking, while postdeployment PTSD symptoms mediated the association between killing in combat and desire for self-harm. These results provide preliminary evidence that suicidal thinking and the desire for self-harm are associated with different mental health predictors, and that the impact of killing on suicidal ideation may be important to consider in the evaluation and care of our newly returning veterans.
  Maguen, S., Metzler, T. J., Litz, B. T., Seal, K. H., Knight, S. J., & Marmar, C. R. (2009). The impact of killing in war on mental health symptoms and related functioning. Journal of Traumatic Stress, 22, 435-443. doi: 10.1002/jts.20451. This study examined the mental health and functional consequences associated with killing combatants and noncombatants. Using the National Vietnam Veterans Readjustment Study (NVVRS) survey data, the authors reported the percentage of male Vietnam theater veterans (N = 1200) who killed an enemy combatant, civilian, and/or prisoner of war. They next examined the relationship between killing in war and a number of mental health and functional outcomes using the clinical interview subsample of the NVVRS (n = 259). Controlling for demographic variables and exposure to general combat experiences, the authors found that killing was associated with posttraumatic stress disorder symptoms, dissociation, functional impairment, and violent behaviors. Experiences of killing in war are important to address in the evaluation and treatment of veterans.
  Maguen, S., Vogt, D. S., King, L. A., King, D. W., Litz, B. T., Knight, S. J., et al. (2011). The impact of killing on mental health symptoms in Gulf War veterans. Psychological Trauma: Theory, Research, Practice, and Policy, 3, 21-26. doi: 10.1037/a0019897. This study examined the impact of killing on posttraumatic stress symptomatology (PTSS), depression, and alcohol use among 317 U.S. Gulf War veterans. Participants were obtained via a national registry of Gulf War veterans and were mailed a survey assessing deployment experiences and postdeployment mental health. Overall, 11% of veterans reported killing during their deployment. Those who reported killing were more likely to be younger and male than those who did not kill. After controlling for perceived danger, exposure to death and dying, and witnessing killing of fellow soldiers, killing was a significant predictor of PTSS, frequency and quantity of alcohol use, and problem alcohol use. Military personnel returning from modern deployments are at risk of adverse mental health symptoms related to killing in war. Postdeployment mental health assessment and treatment should address reactions to killing in order to optimize readjustment.
  Marx, B. P., Foley, K. M., Feinstein, B. A., Wolf, E. J., Kaloupek, D. G., & Keane, T. M. (2010). Combat-related guilt mediates the relations between exposure to combat-related abusive violence and psychiatric diagnoses. Depression and Anxiety, 27, 287-293. doi: 10.1002/da.20659. Background: This study examined the degree to which combat-related guilt mediated the relations between exposure to combat-related abusive violence and both PTSD and Major Depressive Disorder (MDD) in Vietnam Veterans. Methods: Secondary analyses were conducted on data collected from 1,323 male Vietnam Veterans as part of a larger, multisite study. Results: Results revealed that combat-related guilt partially mediated the association between exposure to combat-related abusive violence and PTSD, but completely mediated the association with MDD, with overall combat exposure held constant in the model. Follow-up analyses showed that, when comparing those participants who actually participated in combat-related abusive violence with those who only observed it, combat-related guilt completely mediated the association between participation in abusive violence and both PTSD and MDD. Moreover, when comparing those participants who observed combat-related abusive violence with those who had no exposure at all to it, combat-related guilt completely mediated the association between observation of combat-related abusive violence and MDD, but only partially mediated the association with PTSD. Conclusions: These findings suggest that guilt may be a mechanism through which abusive violence is related to PTSD and MDD among combat-deployed Veterans. These findings also suggest the importance of assessing abusive-violence-related guilt among combat-deployed Veterans and implementing relevant interventions for such guilt whenever indicated.
  Selby, E. A., Anestis, M. D., Bender, T. W., Ribeiro, J. D., Nock, M. K., Rudd, M. D., et al. (2010). Overcoming the fear of lethal injury: Evaluating suicidal behavior in the military through the lens of the Interpersonal-Psychological Theory of Suicide. Clinical Psychology Review, 30, 298-307. doi: 10.1016/j.cpr.2009.12.004. Suicide rates have been increasing in military personnel since the start of Operation Enduring Freedom and Operation Iraqi Freedom, and it is vital that efforts be made to advance suicide risk assessment techniques and treatment for members of the military who may be experiencing suicidal symptoms. One potential way to advance the understanding of suicide in the military is through the use of the Interpersonal-Psychological Theory of Suicide. This theory proposes that three necessary factors are needed to complete suicide: feelings that one does not belong with other people, feelings that one is a burden on others or society, and an acquired capability to overcome the fear and pain associated with suicide. This review analyzes the various ways that military service may influence suicidal behavior and integrates these findings into an overall framework with relevant practical implications. Findings suggest that although there are many important factors in military suicide, the acquired capability may be the most impacted by military experience because combat exposure and training may cause habituation to fear of painful experiences, including suicide. Future research directions, ways to enhance risk assessment, and treatment implications are also discussed.
  Steenkamp, M. M., Litz, B. T., Gray, M. J., Lebowitz, L., Nash, W., Conoscenti, L., et al. (2011). A brief exposure-based intervention for service members with PTSD. Cognitive and Behavioral Practice, 18, 98-107. The growing number of service members in need of mental health care requires that empirically based interventions be tailored to the unique demands and exigencies of this population. We discuss a 6-session intervention for combat-related PTSD designed to foster willingness to engage with and disclose difficult deployment memories through a combination of imaginal exposure and subsequent cognitive restructuring and meaning-making strategies. Core corrective elements of existing PTSD treatments are incorporated and expanded, including techniques designed to specifically address traumatic loss and moral conflict.
  Witvliet, C. V. O., Phillips, K. A., Feldman, M. E., & Beckham, J. C. (2004). Posttraumatic mental and physical health correlates of forgiveness and religious coping in military veterans. Journal of Traumatic Stress, 17, 269-273. doi: 10.1023/B:JOTS.0000029270.47848.e5. This study assessed mental and physical health correlates of dispositional forgiveness and religious coping responses in 213 help-seeking veterans diagnosed with PTSD. Controlling for age, socioeconomic status, ethnicity, combat exposure, and hostility, the results indicated that difficulty forgiving oneself and negative religious coping were related to depression, anxiety, and PTSD symptom severity. Difficulty forgiving others was associated with depression and PTSD symptom severity, but not anxiety. Positive religious coping was associated with PTSD symptom severity in this sample. Further investigations that delineate the relevance of forgiveness and religious coping in PTSD may enhance current clinical assessment and treatment approaches.

  ADDITIONAL CITATIONS Bandura, A. (1999). Moral disengagement in the perpetration of inhumanities. Personality and Social Psychology Review, 3, 193-209. doi: 10.1207/s15327957pspr0303_3. Moral agency is manifested in both the power to refrain from behaving inhumanely and the proactive power to behave humanely. Moral agency is embedded in a broader socio-cognitive self-theory encompassing self-organizing, proactive, self-reflective, and self-regulatory mechanisms rooted in personal standards linked to self-sanctions. The self-regulatory mechanisms governing moral conduct do not come into play unless they are activated, and there are many psychosocial maneuvers by which moral self-sanctions are selectively disengaged from inhumane conduct. The moral disengagement may center on the cognitive restructuring of inhumane conduct into a benign or worthy one by moral justification, sanitizing language, and advantageous comparison; disavowal of a sense of personal agency by diffusion or displacement of responsibility; disregarding or minimizing the injurious effects of ones actions; and attribution of blame to, and dehumanization of, those who are victimized. Many inhumanities operate through a supportive network of legitimate enterprises run by otherwise considerate people who contribute to destructive activities by disconnected subdivision of functions and diffusion of responsibility. Given the many mechanisms for disengaging moral control, civilized life requires, in addition to humane personal standards, safeguards built into social systems that uphold compassionate behavior and renounce cruelty. Fontana, A., & Rosenheck, R. (2004). Trauma, change in strength of religious faith, and mental health service use among veterans treated for PTSD. Journal of Nervous and Mental Disease, 192, 579-584. doi: 10.1097/01.nmd.0000138224.17375.55. One of the most pervasive effects of traumatic exposure is the challenge that people experience to their existential beliefs concerning the
  meaning and purpose of life. Particularly at risk is the strength of their religious faith and the comfort that they derive from it. The purpose of this study is to examine a model of the interrelationships among veterans traumatic exposure, PTSD, guilt, social functioning, change in religious faith, and continued use of mental health services. Data are drawn from studies of outpatient (N = 554) and inpatient (N = 831) specialized treatment of PTSD in Department of Veterans Affairs programs. Structural equation modeling is used to estimate the parameters of the model and evaluate its goodness of fit to the data. The model achieved acceptable goodness of fit and suggested that veterans experiences of killing others and failing to prevent death weakened their religious faith, both directly and as mediated by feelings of guilt. Weakened religious faith and guilt each contributed independently to more extensive use of VA mental health services. Severity of PTSD symptoms and social functioning played no significant role in the continued use of mental health services. We conclude that veterans pursuit of mental health services appears to be driven more by their guilt and the weakening of their religious faith than by the severity of their PTSD symptoms or their deficits in social functioning. The specificity of these effects on service use suggests that a primary motivation of veterans continuing pursuit of treatment may be their search for a meaning and purpose to their traumatic experiences. This possibility raises the broader issue of whether spirituality should be more central to the treatment of PTSD, either in the form of a greater role for pastoral counseling or of a wider inclusion of spiritual issues in traditional psychotherapy for PTSD.
  Hall, J. H., & Fincham, F. D. (2005). Self-forgiveness: The stepchild of forgiveness research. Journal of Social and Clinical Psychology, 24, 621-637. Although research on interpersonal forgiveness is burgeoning, there is little conceptual or empirical scholarship on selfforgiveness. To stimulate research on this topic, a conceptual analysis of selfforgiveness is offered in which selfforgiveness is defined and distinguished from interpersonal forgiveness and pseudo selfforgiveness. The conditions under which selfforgiveness is appropriate also are identified. A theoretical model describing the processes involved in selfforgiveness following the perpetration of an interpersonal transgression is outlined and the proposed emotional, socialcognitive, and offenserelated determinants of selfforgiveness are described. The limitations of the model and its implications for future research are explored.
  Hendin, H., & Haas, A. P. (1991). Suicide and guilt as manifestations of PTSD in Vietnam combat veterans. American Journal of Psychiatry, 148, 586-591. Objective: Although studies have suggested a disproportionate rate of suicide among war veterans, particularly those with postservice psychiatric illness, there has been little systematic examination of the underlying reasons. This study aimed to identify factors predictive of suicide among Vietnam combat veterans with PTSD. Method: Of 187 veterans referred to the study through a Veterans Administration hospital, 100 were confirmed by means of a structured questionnaire and five clinical interviews as having had combat experience in Vietnam and as meeting the DSM-III criteria for PTSD. The analysis is based on these 100 cases. Results: Nineteen of the 100 veterans had made a post-service suicide attempt, and 15 more had been preoccupied with suicide since the war. Five factors were significantly related to suicide attempts: guilt about combat actions, survivor guilt, depression, anxiety, and severe PTSD. Logistic regression analysis showed that combat guilt was the most significant predictor of both suicide attempts and preoccupation with suicide. For a significant percentage of the suicidal veterans, such disturbing combat behavior as the killing of women and children took place while they were feeling emotionally out of control because of fear or rage. Conclusions: In this study, PTSD among Vietnam combat veterans emerged as a psychiatric disorder with considerable risk for suicide, and intensive combat-related guilt was found to be the most significant explanatory factor. These findings point to the need for greater clinical attention to the role of guilt in the evaluation and treatment of suicidal veterans with PTSD.
  Killgore, W. D. S., Cotting, D. I., Thomas, J. L., Cox, A. L., McGurk, D., Vo, A. H., et al. (2008). Post-combat invincibility: Violent combat experiences are associated with increased risk-taking propensity following deployment. Journal of Psychiatric Research, 42, 1112-1121. doi: 10.1016/j.jpsychires.2008.01.001.

  Combat exposure is associated with increased rates of mental health problems such as post-traumatic stress disorder, depression, and anxiety when soldiers return home. Another important health consequence of combat exposure involves the potential for increased risk-taking propensity and unsafe behavior among returning service members. Survey responses regarding 37 different combat experiences were collected from 1,252 US Army soldiers immediately upon return home from combat deployment during Operation Iraqi Freedom. A second survey that included the Evaluation of Risks Scale (EVAR) and questions about recent risky behavior was administered to these same soldiers 3 months after the initial post-deployment survey. Combat experiences were reduced to seven factors using principal components analysis and used to predict post-deployment risk-propensity scores. Although effect sizes were small, specific combat experiences, including greater exposure to violent combat, killing another person, and contact with high levels of human trauma, were predictive of greater risk-taking propensity after homecoming. Greater exposure to these combat experiences was also predictive of actual risk-related behaviors in the preceding month, including more frequent and greater quantities of alcohol use and increased verbal and physical aggression toward others. Exposure to violent combat, human trauma, and having direct responsibility for taking the life of another person may alter an individuals perceived threshold of invincibility and slightly increase the propensity to engage in risky behavior upon returning home after wartime deployment. Findings highlight the importance of education and counseling for returning service members to mitigate the public health consequences of elevated risk-propensity associated with combat exposure.
  MacNair, R. M. (2002). Perpetration-induced traumatic stress in combat veterans. Peace and Conflict: Journal of Peace Psychology, 8, 63-72. doi: 10.1207/S15327949PAC0801_6. The hypothesis that PTSD associated with killing is more severe than that associated with other traumas causing PTSD was tested on US government data from Vietnam War veterans. This large stratified random sample, the National Vietnam Veterans Readjustment Study, allows for generalizable findings. Results showed that PTSD scores were higher for those who said they killed compared to those who did not. Scores were even higher for those who said they were directly involved in atrocities compared to those who only saw them. PTSD scores also remained high for those who said they had killed, but in traditional combat form. The data did not support the alternative explanations that higher battle intensity or a predisposition to over-reporting of symptoms might account for these findings.
  Tangney, J. P., Stuewig, J., & Mashek, D. J. (2007). Moral emotions and moral behavior. Annual Review of Psychology, 58, 345-372. doi: 10.1146/annurev.psych.56.091103.070145. Moral emotions represent a key element of our human moral apparatus, influencing the link between moral standards and moral behavior. This chapter reviews current theory and research on moral emotions. We first focus on a triad of negatively valenced self-conscious emotionsshame, guilt, and embarrassment. As in previous decades, much research remains focused on shame and guilt. We review current thinking on the distinction between shame and guilt, and the relative advantages and disadvantages of these two moral emotions. Several new areas of research are highlighted: research on the domain-specific phenomenon of body shame, styles of coping with shame, psychobiological aspects of shame, the link between childhood abuse and later proneness to shame, and the phenomena of vicarious or collective experiences of shame and guilt. In recent years, the concept of moral emotions has been expanded to include several positive emotionselevation, gratitude, and the sometimes morally relevant experience of pride. Finally, we discuss briefly a morally relevant emotional processother-oriented empathy.
  

• VA testing whether meditation can help treat PTSD
  By Steve Vogel, Published: May 3 The Washington Post

  Seeking new ways to treat post-traumatic stress, the Department of Veterans Affairs is studying the use of transcendental meditation to help returning veterans of Iraq and Afghanistan.

  Veterans Affairs $5.9 billion system for mental-health care is under sharp criticism, particularly after the release of an inspector generals report last month that found that the department has greatly overstated how quickly it treats veterans seeking mental-health care.

  VA has a huge investment in mental-health care but is seeking alternatives to conventional psychiatric treatment, said W. Scott Gould, deputy secretary of veterans affairs.

  The reality is, not all individuals we see are treatable by the techniques we use, Gould said at a summit Thursday in Washington on the use of TM to treat post-traumatic stress suffered by veterans and active-duty service members.

  By some estimates, 10 percent of veterans returning from Iraq and Afghanistan show effects of post-traumatic stress disorder, numbers that are overwhelming the department

  Conventional approaches fall woefully short of the mark, so we clearly need a new approach, said Norman Rosenthal, a clinical professor of psychiatry at Georgetown Universitys medical school.

  Rosenthal told the gathering that TM, a meditative practice that advocates say helps manage stress and depression, is possibly even a game-changer in how to treat PTSD.

  VA is spending about $5 million on a dozen clinical trials and demonstration studies of three meditation techniques involving several hundred veterans from a range of conflicts, including Iraq and Afghanistan. Results from the studies will not be available for 12 to 18 more months.

  But Gould said he was encouraged by the results of other trials presented at the summit.

  Two independent pilot studies of Iraq and Afghanistan veterans showed a 50 percent reduction in symptoms of post-traumatic stress after eight weeks, according to the summits sponsor, the David Lynch Foundation, a charitable organization founded by the American filmmaker and television director.

  Results from the initial phase of a long-term trial investigating the effects of TM on 60 cadets at Norwich University, a private military college in Vermont, have shown promise, school officials said at the summit.

  Students practising TM at Norwich showed measurable improvement in the areas of resilience, constructive thinking and discipline over a control group not using the method. The statistical effect we found in only two months was surprisingly large, Carole Bandy, an associate professor of psychology who is directing the Norwich study, said at the summit.

  For us, its all about the evidence, said Norwich President Richard W. Schneider, who added that he was a skeptic before the trial began.

  Operation Warrior Wellness, an initiative of the David Lynch Foundation, is providing TM training to troops recovering from wounds at Joint Base Lewis-McChord in Washington state. Soldiers report dramatic improvements in sleep, according to the foundation, as well as significant reductions in pain, stress and the use of prescription medications.

  Lynch, the director of Blue Velvet, Mulholland Drive and the television series Twin Peaks, is a longtime practitioner of TM.

  The VA is very interested in what this can do, Lynch said in a telephone interview Thursday. He acknowledged that many in the military are wary of transcendental meditation, with its New Age and mystic connotations.

  Big-time, Lynch said. Theyre skeptical until they start hearing stories, or experiencing it for themselves.

• Wounds That Cannot Wait
  WASHINGTON, D.C.Today, Rep. Jeff Miller, Chairman of the House Committee on Veterans Affairs, issued the following statement on VAs announcement to hire additional mental health practitioners:
  Today, VA announced that they are hiring 1,900 new mental health care practitioners. We have seen high vacancy rates across the countrywhich in some areas are as high as 23 percentand this is a start to ensure our veterans receive the care they need.
  There is much more, however, that VA needs to do to address gaps in services and ensure veterans undergoing treatment are not lost in the system.
  I expect VA to also increase training of employees who are the first touch points for veterans suffering from Post-Traumatic Stress (PTS) to provide effective intervention when it is needed most and properly identify the signs and behaviors of suicide risk. It is also imperative that wait times for those seeking care are decreased. These are wounds that cannot wait.
  Further, I expect VA to submit a revised budget detailing how funds for mental care are being reallocated and account funding that may have been diverted to other accounts and put back into mental health, where it rightfully belongs.
  There are a surge of veterans coming home, and VA must be prepared to meet their needs. If they are unable to do so, it is imperative that VA find community-based providers to match the right treatment for each veteran. Right now, too many veterans fall through the cracks. We can avert tragedy with the proper outreach and care. I am hopeful VAs decision today, stemming from years of pressure and increased funding from Congress, will expand access for veterans and help them lead full and long lives.
  For more news from the House Committee on Veterans Affairs, please visit:
  Veterans.House.Gov
  Find us on Facebook at: Facebook.com/HouseVetsAffairs or follow us on Twitter at:
  @HouseVetAffairs
  ###
  News From The
  COMMITTEE ON VETERANS' AFFAIRS
  Jeff Miller, Chairman, 335 Cannon House Office Building, Washington D.C. 20515

• Army reports mixed picture on soldier mental health
  suicides decline, but violence climbing

  PAULINE JELINEK , Associated Press Updated: January 19, 2012 - 1:54 PM

  . WASHINGTON - The number of suicides among soldiers has been leveling off but there's been a dramatic jump in domestic violence, sex crimes and other destructive behavior in a force that has been stressed by a decade of war, a new Army report said Thursday.

  "There's a lot of good news in this report, but there's also some bad news," Army Vice Chief of Staff Gen. Peter Chiarelli told a Pentagon press conference. "We know we've got still a lot of work to do."

  Suicides among soldiers in the active duty, Guard and Reserve totaled 278 last year, down 9 percent from 2010.

  "I think we've at least arrested this problem and hopefully will start to push it down," Chiarelli said.

  But violent sex crimes and domestic violence have increased more than 30 percent since 2006 and child abuse by 43 percent.

  "After 10 years of war with an all-volunteer force, you're going to have problems that no one could have forecasted before this began," he said.

  Chiarelli was releasing a 200-page report for commanders, health care providers and other military leaders and meant to assess the physical and mental health condition of the force, disciplinary problems, and any gaps in how the Army deals with them.

  It follows up on a 2010 report that said the Army was failing some soldiers by missing signs of trouble or by looking the other way as commanders tried to keep up with tight deployment schedules needed to fight in both Iraq and Afghanistan.

  Chiarelli said commanders are now getting more troops into substance abuse programs; are kicking more out of the service for misconduct, and are barring others with alcohol and drug convictions from joining in the first place.

  Other details from the report:

  _ Calling post-traumatic stress disorder an epidemic, it estimates that there could be 472,000 service members with the condition, half of them in the Army.

  _Some 24,000 soldiers were referred to substance abuse programs in the 2011 budget year, ended in September.

  _The Army had over 126,000 diagnosed cases of traumatic brain injury from 2000 to 2010. That included more than 95,000 mild cases such as concussions, 20,000 moderate cases and more than 3,500 in which there were severe, penetrating injuries.

  Chiarelli said the military has taken "a huge step forward" with new screening procedures for troops who get concussions a frequent injury in wars where makeshift bombs have been insurgents' weapons of choice. Troops are now taken off the battlefield and held off for days or weeks until they recover, he said.

• Veterans with posttraumatic stress disorder to receive health care for life
  By Michael Doyle - Bee Washington Bureau
  http://www.fresnobee.com/2012/01/13/2682680/veterans-with-post-traumatic-stress.html
  
  Friday, Jan. 13, 2012
  WASHINGTON -- A federal judge has quietly approved a settlement that will deliver better benefits to nearly 2,100 veterans who've been medically discharged since 2002 with post-traumatic stress disorder.
  Under the settlement, one of several similar efforts now under way, affected veterans discharged with PTSD will get lifetime health care and post-exchange privileges. The affected veterans had been discharged with disability ratings that were too low to receive such benefits.
  Anthony Koller, for one, is an Army veteran who lives in Little Elm, Texas , about 50 miles north of Fort Worth . He survived 14 months in Iraq before being discharged with PTSD. His initial low disability rating, though, left the married father of three adrift.
  "We live on a month-to-month basis," Koller said in a court declaration.
  Under the recently approved class-action settlement, Koller's family will receive health care under TRICARE, and he can apply for special compensation payments, among other benefits.
  Chris Crotte of Sacramento was medically discharged with PTSD in April 2008 after two tours in Iraq as a forward observer with the 17th Field Artillery Brigade. His back, he said, was "messed up." He slept poorly. His mind was jumpy. Officials marked him as only 10% disabled and cut him loose.
  "I got out, and hit the road," Crotte said. "I constantly bounced around; I was moving from state to state for a while."
  Now, he's studying auto mechanics and living in West Sacramento . "Getting medical care would be good," he said.
  From December 2002 to October 2008, the military medically discharged about 4,300 soldiers, sailors, airmen and Marines with PTSD and disability ratings below 50%.
  The military services, veterans advocates charged in court, were "engaged in a transparent effort to purge their ranks" and cut costs.
  Under congressional pressure in 2008, the Defense Department agreed to grant 50% disability ratings to those diagnosed with PTSD in the future. That policy change, though, came too late for some.
  "The individual service branches have done nothing to address their mistreatment of potentially thousands of veterans they already have abandoned," Washington-based attorney Brad Fagg wrote in the lawsuit, originally filed in December 2008.
  The settlement provides lifetime disability retirement benefits to 1,029 veterans with PTSD who'd been denied aid previously. An additional 1,066 will have their disability benefits increased.
  Another 2,200 potentially affected veterans didn't opt in to the class-action lawsuit, though they might take individual legal action.
  Separately, the Defense Department has created the Physical Disability Board of Review, which is empowered to revise the status of veterans who were medically discharged with less than 30% disability ratings from Sept. 11, 2001, through Dec. 31, 2009. While the class-action lawsuit was limited to PTSD cases, the special review board can examine any type of medical discharge.
  Potentially, 74,374 medically discharged veterans are eligible to apply. So far, only about 3,200 have done so.
  The reporter can be reached at mdoyle@mcclatchydc.com or (202) 383-0006. Follow him on Twitter: @MichaelDoyle10.

• PTSD Research Quarterly NOV2011
  RQ Vol. 22(3) Trauma and PTSD in Japan
  Fran H. Norris, PhD
  The PTSD Research Quarterly is a guide to the research literature on a particular topic. This issue is the third in a series on trauma and PTSD around the world.*
  
  This Months Feature: Honoring All of Our Veterans Veterans Day 2011
  
  Not all Veterans have seen war, but they share an oath in which they expressed their willingness to die defending this nation. We take this opportunity to express our humble thanks to all of those outstanding men and women who sacrificed for us and our country. For those Veterans who served, as well as for those who now serve in the Active Duty and Reserve Components, and each and every one of their family members, in both peacetime and in war thank you.
  
  True appreciation is better expressed in action. Do something in the next week to help a Veteran. Employers: consider hiring a Veteran; teachers: ask if children have parents that deployed to war, campus personnel: provide adult Veteran students some time to reintegrate into civilian life; primary care doctors: remember to ask your patients about trauma and screen for PTSD. Community members all are stepping up, because as a whole, American society has learned over time from the sacrifices of Veterans who have come before.
  
  This PTSD Monthly Update contains information that is pertinent across all eras of Veterans; from those who have recently served, to the largest group of Veterans we have, Vietnam Veterans, who along with all of us, are now aging.
  
  Learn about trauma in our military including the unique effects of the Persian Gulf War, the mental health effects on our recently returning Service Members, military sexual trauma, and how older Veterans may develop symptoms later in life. If you or someone you know is a Veteran in need of help with symptoms that developed following war or other trauma, see Help for Veterans with PTSD, call VAs new program Coaching into Care, or talk to another Veteran on the 24/7 Veteran Combat Call Center: 1-877-927-8387 (WAR-VETS).
  
  Although there are universal effects of trauma on all humans, individuals differ. These differences can lead to some special considerations. The era a Veteran served in, ethnicity, and trauma type can have some effect. View one of six different videos on specific considerations for women, Latino, African-American, Native American, Asian American and Pacific Islander Veterans.
  
  Research at NCPTSD
  Check out our new web page on PTSD Research for Veterans and the general public. Learn why research is important and what to consider when thinking about participating in research. You can also search for ongoing studies around the country and find out about specific research being done at the National Center for PTSD.
  For Providers
  As you know, war involves more than combat. The effects of war also include casualty and death notification, military sexual trauma, and the impact of trauma on civilians. The National Center for PTSD provides you some specific information about treating Veterans, including the Iraq War Clinician Guide. Also included is treatment information on ethnic minority Veterans and Findings from the National Vietnam Veterans' Readjustment Study.
  
  Learn more about the course of PTSD in older adults and the impact of aging on PTSD in the new PTSD 101 course: Aging and PTSD, or find out what we know about Resilience to Stress and Trauma.

  
  VA Providers
  The VA PTSD Consultation Program can now take calls from any VA staff member (or contractor being paid by VA to provide care) working with Veterans, providing free consultation on PTSD care. Questions this week included consults about PTSD residential programs for different populations of Veterans, treating dissociative symptoms, and redesigning groups in PTSD clinics and in CBOCS. We are working hard to provide information to the community of clinicians that are working even harder to help our Veterans. No question is too simple or too complex!
  For a consult call 1-866-273-8255, email PTSDConsult@va.gov or submit the online form.
  Teleconference Series on PTSD Consultation: Starting next year, VA staff can join a series of educational teleconferences based on what we have learned from questions previously posed by providers. To sign up, contact 314-894-6648 x63334 or Erica.Jackson2@va.gov. Starts January 2012: 3rd Tuesday of the month, 2-3 PM EST.
  Other PTSD News
  PTSD Coach App can help you learn about and manage symptoms that commonly occur after trauma. Free to download for iPhone and Android. It recently won a prestigious FCC Award for Advancement in Accessibility: Helping more people benefit from technology. Read more
  
  
  
  
  PTSD Materials for Printing can now be downloaded, along with printing instructions. Find a What is PTSD brochure or business sized tri-fold card to use at your next event, or Returning from the War Zone Guides, Understanding PTSD Treatment booklets, a Resource List for Providers, and more.
  
  Finding the proper resources to help a Veteran or family member can be daunting. The National Resource Directory helps navigate through over 10,000+ resources on health, including mental health, as well as:
  Benefits & Compensation
  Education & Training
  Employment
  Family & Caregiver Support
  Housing Assistance
  
  4th Annual Trauma Spectrum Conference
  Register now for this DoD/VA conference in Bethesda, MD, Dec. 8-9. Covers available resources and best practices for psychological health and TBI for those involved in health care, clinical practice and research for Service Members and Veterans.
  
  Please encourage your colleagues and others to subscribe to this monthly listserv!
  
  Sincerely,
  The Staff of the National Center for PTSD
  
  *following previous issues on Latin America (Fall 2009) and the Middle East (Fall 2010)
  ---------------------------------------
  
  Subscribe to this listserv or other products from the VA National Center for PTSD.

  Risk Factors for Posttraumatic Stress Symptomatology
  in Iraq and Afghanistan War Veterans Similar
  to Those Observed in Vietnam Veterans
  Women Veterans Face New Risk Factors
  
  WASHINGTON Department of Veterans Affairs (VA) researchers from Boston report in the November issue of the Journal of Abnormal Psychology that risk factors for posttraumatic stress symptomatology (PTSS, short of full-blown posttraumatic stress disorder, or PTSD) in Afghanistan and Iraq Veterans were found to be similar to those observed in Vietnam Veterans. This suggests that there may be generalized mechanisms and pathways, common to different Veteran populations, through which risk factors contribute to PTSS.
  This research underscores the vital importance of VAs outreach to Veterans, and their families, in helping them cope with posttraumatic stress, said Secretary of Veterans Affairs Eric K. Shinseki.
  The study subjects were a national sample of 579 (333 female and 246 male) Iraq and Afghanistan Veterans exposed to combat operations who had returned from deployment in the 12 months preceding the study. Using data from mailed surveys, the researchers assessed, as predictors of posttraumatic stress symptomatology, several risk factors which were previously documented among Vietnam Veterans. Examples include exposure to combat, predeployment stress exposure, dysfunctional family during childhood, lack of post-deployment emotional support from family and friends, and post-deployment stress exposure.
  An interesting finding was that the women Veterans surveyed had new risk factors that were not seen in Vietnam-era women, such as exposure to combat and perceived threat. The authors ascribed that finding to the significantly different experiences of female Vietnam War and Afghanistan and Iraq war Veterans. Women Vietnam Veterans were primarily nurses or clerical staff. In contrast, women Veterans roles in Afghanistan and Iraq have substantially expanded, with much higher levels of exposure to combat. Thus, women Veterans in these more recent conflicts may have more in common with their male contemporaries, in relation to PTSS risk, than with their female counterparts from the Vietnam era. However, in terms of postdeployment readjustment, family relationships during deployment appeared to play a more prominent role in female compared to male Veterans.
  Our findings highlight the impact and role of family disruptions in increasing the risk for posttraumatic stress symptomatology, particularly for female servicemembers, said Dr. Dawne Vogt, the papers lead author, from the VA Boston Healthcare System. It is particularly noteworthy that women who experienced relationship problems during deployment, also reported less postdeployment social support.
  Veterans who believe they are experiencing symptoms of PTSS or PTSD may call the crisis hotline number at 1-800-273-TALK (8255) and then push 1 on their telephone keypad to reach a trained VA mental health professional who can assist the Veteran 24 hours a day, seven days a week.

• By Alex Horton July 22, 2011 at 10:58 am

• Its difficult to find the right treatment for post-traumatic stress after its diagnosed. Experiences and intensities vary from person to person, and everyone responds differently to treatment. Many Veterans have reported, at an alarming rate, about their reliance on prescription drugs to ease the symptoms of PTSD. Drug cocktails may not be the best option to treat a potentially life-long condition when there are several other alternative therapy options.

  Luckily alternative treatments for PTSD are continually developed and refined. One that caught my attention is called Eye Movement Desensitization and Reprocessing. I wont pretend to understand the method, but the Boston Globe describes it well:

  The therapy typically requires the patient to focus on blinking lights or a practitioners finger moving back and forth, usually for a few minutes at a time, while recalling the disturbing memories. In some instances, alternating tones in the ears or electrical pulses in the palms are used instead of visual cues.
  EMDR is among the top recommended treatments of PTSD by VA, which also include cognitive behavioral therapy and exposure therapy. Steve Girard, the Veteran in the story, had positive results with EMDR.

  PTSD treatment isnt one size fits all, so if youre looking for a way to cope and dont like the idea of medication, perhaps a few of these therapies will suit you better.

• Acupuncture Makes Strides in Treatment of Brain Injuries and PTSD
  Written on June 20, 2011 at 2:23 pm by Carla Voorhees
  http://science.dodlive.mil/2011/06/20/acupuncture-makes-strides-in-treatment-of-brain-injuries-ptsd-video/

  Military field physicians are using the practice of acupuncture to treat cases of mild traumatic brain injuries (mild TBI), including concussions, and cases of post-traumatic stress disorder (PTSD).
  We think its important to work on these as a team and address both issues at the same time to try to get a Marine back on his feet and heading in the right direction, said Navy Cmdr. (Dr.) Charlies Benson, a psychiatrist and surgeon with the 1st Marine Expeditionary Force.
  Acupuncture, a form of alternative medicine, treats patients by the insertion and manipulation of needles in the body. It has been known to relieve pain, treat infertility and diseases, and prevent diseases.
  Operation Stress Control and Readiness Program, a joint Navy-Marine Corps effort, embeds psychiatrists and psychologists within combat teams to provide mental health care to troops in Afghanistan. The program trains medical officers, corpsmen, chaplains, religious personnel and key leaders at the sergeant and first sergeant level to deliver basic mental health services. Troops also have the option to see physical therapists, occupational therapists, and acupuncturists at an outpatient concussion center to address physical and emotional impacts of combat-related injuries.
  Having psychiatrists and psychologists embedded in regiments and battalions gives troops who might not naturally turn to a mental health provider a range of ways to seek help, Benson said.
  Mild TBI is an especially challenging injury to treat, Bensen said, adding that it is a physical injury, which often includes psychological symptoms including insomnia, headaches, nightmares and anxiety.
  When folks have a mild traumatic brain injury, sometimes their symptoms have a psychiatric flavor, Bensen said. They might have difficulty sleeping or nightmares and anxiety along with that.
  As it turns out, PTSD symptoms are very similar to those of mild TBI insomnia, headaches, memory problems, attention problems, anxiety and irritability. Studies have shown that acupuncture is an effective treatment for PTSD, leading Navy Cmdr. (Dr.) Keith Stuessi, former director of the Concussion Restoration Care Center at Camp Leatherneck in Afghanistan to believe the treatment could be used for mild TBI as well.
  Stuessi describes the Concussion Restoration Care Center as a success treating more than 320 concussion patients thus far. Of the more than 20 troops he personally treated, almost all saw marked improvements in their sleep, anxiety levels and frequency of headaches. Cmdr. Earl Frantz, who replaced Steussi at Camp Leatherneck in March, continued the practice of using acupuncture on troops with symptoms of mild TBI.
  The Department of Defense is putting its weight behind acupuncture. For example, the most recent Veterans Affairs (VA) clinical guidance recommends acupuncture as a supplementary therapy for PTSD, anxiety, pain and sleeplessness. The VA is even recruiting candidates for a formal study of acupunctures effectiveness on PTSD and mild TBI.
  For more information about acupuncture and its use to treat mild TBI and PTSD, watch the following videos of Cmdr. Steussi, and a piece by American Forces Network Afghanistan.

• VA/DOD Smart Phone App Helps Veterans Manage PTSD
  April 19, 2011

  WASHINGTON Veterans dealing with symptoms of Post Traumatic Stress Disorder (PTSD) can turn to their smart phones for help anytime with the PTSD Coach application created by the Department of Veterans Affairs (VA) and the Department of Defense.
  This is about giving Veterans and Servicemembers the help they earned when and where they need it, said Secretary of Veterans Affairs Eric K. Shinseki. We hope they, their families and friends, download this free app. Understanding PTSD and those who live with it is too important to ignore.
  PTSD Coach lets users track their PTSD symptoms, links them with local sources of support, provides accurate information about PTSD, and teaches helpful individualized strategies for managing PTSD symptoms at any moment. The free PTSD Coach app is now available for download from the iTunes store and will be available for Android devices by the end of the spring.
  This application acknowledges the frequency with which our Warriors and Veterans use technology and allows them to get help when and where they feel most comfortable, said Assistant Secretary of Defense for Health Affairs Dr. Jonathan Woodson.
  The PTSD Coach is primarily designed to enhance services for individuals who are already receiving mental health care, though it is certainly helpful for those considering entering mental health care and those who just want to learn more about PTSD.
  This is a great service we are providing to Veterans, Servicemembers, their families and friends, but it should not be seen as a replacement for traditional therapy, said VAs Under Secretary for Health Dr. Robert Petzel. Veterans should utilize all of the benefits they have earned with their service and one of the best things about this app is it will get Veterans connected to the places that are out there to provide help.
  The application is one of the first in a series of jointly designed resources by the VA National Center for PTSD and the Defense Department's National Center for Telehealth and Technology to help Servicemembers, Veterans, their families and friends manage their readjustment challenges and get anonymous assistance. Given the current popularity of mobile devices, VA and the Defense Department hope to reach tens of thousands of Veterans, Servicemembers, and their family members with the new suite of apps.
  # # #
  Information on the PTSD Coach app is on the VAs National Center for PTSD Website: http://www.ptsd.va.gov/public/pages/PTSDCoach.asp. More apps from DoD's National Center for Telehealth and Technology can be found at: http://www.t2health.org/apps.

  Coping with the Stress of PTSD and Other Situations

My husband is a Vietnam Veteran who suffers intensely with Post Traumatic Stress Disorder. It doesn't take much to push his buttons -- especially me! Perhaps that is why he prefers that I deal with difficult situations because he knows he has a short fuse and will blow up! When the situation occurred at the VA Hospital, I was thankful he did not hear the nurse's comments. All he heard was me, when I spun on my heel and retaliated. It took all of my self-control not to go on the attack with the nurse. I am certain that now she probably regrets saying, "You can always go somewhere else..." I hope her words taught her something about biting her tongue -- and being diplomatic.

Perhaps some of you have not lived with a Veteran who battles with PTSD. My husband only shows his true behaviors of the PTSD side effects behind the closed doors of our home. Yes, there are times he gets impatient with others, and some people have asked me how I tolerate these situations. I simply smile, inhale, exhale and say that 'this too shall pass...' I've lived with him for many years and I know the triggers, along with the curious, vacant stare in his eyes. It's a look I do not like -- the look of a warrior, headed to battle, facing the unknown.

It is true -- I haven't forgotten the loneliness, apprehension and fear that a wife, husband or family member experiences when a loved one leaves for war. And it is also true, I anticipated that when he returned, he would still be the young, happy and loving soldier he was before he left to fight for our country. Trust me...when a soldier returns from a combat zone -- life is changed -- significantly. No one can understand what they experienced, and perhaps that is why they NEVER talk about these situations.

I suppose my husband is appreciative that I tolerate what PTSD does to him. As his wife, I do not hold it against him. I made the commitment to be with him, 'in sickness and in health,' when we married. After he returned from war - a stranger who refused to discuss the war -- I read articles about PTSD, recognizing he had many of the symptoms, and when he finally admitted he might suffer from it, I replied, "I may not be a medical professional, but I live with you and I KNOW you have it!"

Sharing Our Experience

After our experience at Ralph H. Johnson VA Medical Center, my husband shook his head when he discovered I was composing a story about the incident. "You're just wasting your time," he said. "It won't do a bit of good." How thankful I was that he did not hear the nurse's comments, just my response. When he saw the anger and emotions in my face, he knew something had happened. As a professional writer, I am accused of wearing my emotions on my shirt sleeves and no doubt, my heart was about to burst from the anger I was struggling to hold back on that date.

After completing the story, I printed it, read it to him and packaged the composition ready for mail. After posting on my blog, I was curious if people actually read it. Last Thursday, I discovered the story was making the rounds and people were listening...

So, the bottom line -- when dealing with a difficult situation -- be diplomatic. Inhale. Exhale. Breathe. And if the anger cannot be controlled -- simply walk away. Document everything by collecting names, dates, times, etc. Assert yourself about the situation by placing your feet in the shoes of the situation. While it is true there are many complaints about the length of time it takes to get service at a VA Hospital, or with the VA Administration, we are still dealing with people and I fully believe every situation is unique. As for the response from Ralph H. Johnson VA Medical Center, I truly appreciate that they took the time to read the story and to do a thorough investigation. Our Veterans deserve diplomacy and patience. After all, they have been fighting wars and most of them never share their experiences during those traumatic times. We as caring family members and medical professionals must treat them with respect, especially if they are suffering from illnesses, PTSD, and the little incidental sufferings only a Veteran can understand.

Thank you, Ralph H. Johnson VA Medical Center for listening to me and my husband's experience. It is nice to know that you are listening to us and working towards providing some of the best medical care you have available. Yes, Diplomacy pays!

ABOUT THE AUTHOR: Barbie Perkins-Cooper is the proud wife of a Vietnam Veteran and an award winning screenwriter, travel writer and a freelance writer who loves the journey and exploration of stories and how they educate or inspire the reader. She works full-time as an editorial photojournalist and has published numerous articles and photographs for regional, health and beauty, hospitality and travel publications including Convention South, Travel Channel, Texas Co-op Power, AAA Midwest Traveler, Kentucky Monthly, and Buick Magazine and others and she writes a travel and food blog. Barbie resides in Charleston, South Carolina with her husband, Phil and three precious pups. She volunteers as an advocate for Veterans-for-Change promoting public relations for the issues and emotional battles for Veterans, and she serves as the editor of Mail Call for a local Veterans of Foreign Wars. She is a member of the prestigious American Society of Journalists and Authors [ASJA] and the Society of Professional Journalists. Barbie is the author of Condition of Limbo and Career Diary of a Photographer. Visit her website www.barbieperkinscooper.com

PTSD Update
Latest Issue:
RQ Vol. 22(1) PTSD and the Law: An Update
Jim McGuire, PhD, Director, and Sean Clark, JD, National Coordinator: VHA Veterans Justice Outreach Program

This Months Feature: PTSD and the law

Symptoms of PTSD can range from mild to severe. At times the symptoms may make it more likely that the sufferer will get in trouble with others, or with the law. Although thoughts, level of arousal, and feelings may be affected by PTSD, there is no evidence that even severe PTSD in anyway causes criminal behavior (see Criminal behavior and PTSD).

At the same time, recent legal cases have considered combat stress as a mitigating factor at sentencing. PTSD can affect the way a person sees, thinks, or responds to people and situations. Trauma survivors with PTSD may be more prone to feeling threatened in situations, even when this is not warranted.

Anyone who experiences trauma, including those who deal with PTSD, can get care (see Where to Get Help for PTSD). Effective treatment can reduce symptoms. This may decrease the chances of getting in trouble with the law. For U.S. Veterans who experienced trauma in service to our country, resources exist to help ensure that needed care is provided.

Smart Phone App PTSD COACH Free Download from iTunes
Announcing the release of PTSD Coach, a free iPhone app (Android coming soon.) If you have, or think you might have PTSD, this app is for you.
Family and friends can also learn from this app. See what others are saying about the new app:

A New Way to Serve our Veterans, by Secretary Eric K. Shinseki of the Department of Veterans Affairs, also on the Whitehouse Blog.

On the VA Blog with app developer Dr Julia Hoffman.

Resources for justice-involved Veterans

There is help for Veterans with PTSD who may get in trouble with the law. Programs from VA and others give justice-involved Vets the chance to get treatment rather than face time in jail if they are dealing with mental health issues. State legislatures support Veterans by directing courts to address the mental health status of Veterans in their courts. In many communities, police and other law enforcement are trained to handle mental health crises and to ask if a person is a Veteran. The focus is on treatment, rather than on incarceration.

Veterans Justice Outreach (VJO) Program
Each VA Medical Center has a Veterans Justice Outreach specialist. VJOs help justice-involved Veterans suffering from PTSD or other mental health issues avoid unnecessary punishment and jail time.

VJOs help Veterans get access to VHA mental health and other VA services and benefits. They work with public defenders, providers, community and Veterans organizations, the courts, and others to find ways to help justice-involved Veterans rather than punish them.

Find VJO Contacts at your local VA Medical Center.

Veterans Treatment Courts
In many communities courts are set up to help Keep Veterans with PTSD out of the Justice System. These courts help get Veterans who are in need of mental health or substance abuse treatment the treatment and tools for readjustment that they need. Only Veterans charged with non-violent crimes may go to treatment court.
Veterans Treatment Courts form partnerships with VA and other Veterans organizations. If a Veteran is arrested, eligibility for Veterans Treatment Court and for VA benefits is determined.
VA Health Care for Reentry Veterans Services and Resources
To prevent homelessness and other problems associated with leaving prison, this program helps provide information to Veterans while they are incarcerated so they may plan for re-entry themselves.

For Providers and Researchers
Changes in cognition, heightened arousal, and a range of emotional issues may increase the likelihood that persons with PTSD will get in trouble with others or with the law. The new issue of the PTSD Research Quarterly: PTSD and the Law: An update (PDF) and Criminal Behavior and PTSD: An Analysis provide you with more detail on this issue.

Community Support for those with PTSD
Education and increased awareness can help prevent incarceration of persons who are dealing with mental health issues. Law enforcement officials, college counselors, employers and coworkers can learn more about common reactions following war and other trauma, including Understanding PTSD.

PTSD's Diagnostic Trap
Military history is rich with tales of warriors who return from battle with the horrors of war still raging in their heads. One of the earliest examples was enshrined by Herodotus, who wrote of an Athenian warrior struck blind "without blow of sword or dart" when a soldier standing next to him was killed. The classic term--"shell shock"--dates to World War I; "battle fatigue," "combat exhaustion," and "war stress" were used in World War II.
Modern psychiatry calls these invisible wounds post-traumatic stress disorder (PTSD). And along with this diagnosis, which became widely known in the wake of the Vietnam War, has come a new sensitivity--among the public, the military, and mental health professionals--to the causes and consequences of being afflicted. The Department of Veterans Affairs is particularly attuned to the psychic welfare of the men and women who are returning from Operation Iraqi Freedom and Operation Enduring Freedom. Last July, retired Army General Eric K. Shinseki, secretary of Veterans Affairs, unveiled new procedures that make it easier for veterans who believe they are disabled by wartime stress to file benefit claims and receive compensation."[Psychological] wounds," Shinseki declared, "can be as debilitating as any physical battlefield trauma."
This is true. But gauging mental injury in the wake of war is not as straightforward as assessing, say, a lost limb or other physical damage. For example, at what point do we say that normal, if painful, readjustment difficulties have become so troubling as to qualify as a mental illness? How can clinicians predict which patients will recover when a veteran's odds of recovery depend so greatly on nonmedical factors, including his own expectations for recovery; social support available to him; and the intimate meaning he makes of his distress? Inevitably, successful care giving will turn on a clear understanding of post-traumatic stress disorder.

According to the Columbia reanalysis, the psychological cost of the war was 40 percent lower than the original NVVRS estimate.One of the most important and paradoxical lessons to emerge from these insights is that lowering the threshold for receipt of disability benefits is not always in the best interest of the veteran and his family. Without question, some veterans will remain so irretrievably damaged by their war experience that they cannot participate in the competitive workplace. These men and women clearly deserve the roughly $2,700 monthly tax-free benefit (given for "total," or 100 percent, disability) and other resources the Veterans Administration offers. But what if disability entitlements actually work to the detriment of other patients by keeping them from meaningful work and by creating an incentive for them to embrace institutional dependence? And what if the system, well-intentioned though it surely is, does not adequately protect young veterans from a premature verdict of invalidism? Acknowledging and studying these effects of compensation can be politically delicate, yet doing do is essential to devising reentry programs of care for the nation's invisibly wounded warriors.

What Is PTSD
The most recent edition of the Diagnostic and Statistical Manual (DSM IV) of the American Psychiatric Association defines PTSD according to symptoms; their duration; and the nature of the "trauma" or event. Symptoms fall into three categories: re-experiencing (e.g., relentless nightmares; unbidden waking images; flashbacks); hyper-arousal (e.g., enhanced startle, anxiety, sleeplessness); and phobias (e.g., fear of driving after having been in a crash). These must persist for at least 30 days and impair function to some degree. Overwhelming calamity--or "stressor," as psychiatrists call it--of any kind, such as a natural disaster, rape, accident, or assault, can lead to PTSD.
Notably, not everyone who confronts horrific circumstances develops PTSD. Among the survivors of the Oklahoma City bombing, for example, 34 percent developed PTSD, according to a study by psychiatric epidemiologist Carol North. After a car accident or natural disaster, fewer than 10 percent of victims are affected, while among rape victims, well over half succumb. The reassuring news is that, as with grief and other emotional reactions to painful events, most sufferers get better with time, though periodic nightmares and easy startling may linger for additional months or even years.

In contrast to the sizeable literature on PTSD in civilian populations and in active-duty soldiers, data on veterans are harder to come by. To date, the congressionally mandated National Vietnam Veterans Readjustment Study (NVVRS) remains the landmark analysis. Data were collected during 1986 and 1987 and revealed that 15.2 percent of a random sample of veterans still met criteria for PTSD. Yet, a number of scholars found those estimates to be improbably high (e.g., if roughly one in six Vietnam veterans suffered from PTSD, as the NVVRS suggests, this would mean that virtually each and every soldier who served in combat--a ratio of 1 combatant to every 6 in support specialties--developed the condition). To help clarify the picture, a team of researchers from Columbia University undertook a reanalysis of the NVVRS. After their results appeared in Science in 2006, it became impossible for responsible researchers to consider the original findings of NVVRS as definitive.

According to the Columbia reanalysis, the psychological cost of the war was 40 percent lower than the original NVVRS estimate--that is, 9.1 percent were diagnosed with PTSD at the time of the study. The researchers arrived at this prevalence rate by considering information--collected by the original NVVRS investigators but not used--on veterans' functional impairment (i.e., their ability to hold a job, fulfill demands of family life, maintain friendships, etc). However, the Columbia team used a rather lenient definition of "impairment," stipulating that even veterans with "some difficulty" but who were "functioning pretty well" despite their symptoms had PTSD. This spurred yet another reanalysis. In a 2007 article in the Journal of Traumatic Stress, Harvard psychologist Richard McNally took the definition of impairment up a notch so that only veterans who had at least "moderate difficulty" in social or occupational functioning could qualify as having PTSD. In doing so, he further reduced the estimate of affliction to 5.4 percent. If nothing else, this analytic sequence--from the NVVRS, to the Columbia reevaluation, and to the McNally recalibration--serves as an object lesson in the definitional fluidity of psychiatric syndromes.

From the wars in Iraq and Afghanistan, researchers have collected data on thousands of active-duty servicemen, but very little on veterans of those conflicts. The most rigorous evaluation to date appeared in the Archives of General Psychiatry last summer. It was conducted by investigators at the Walter Reed Army Institute of Research who applied rigorous and uniform diagnostic standards. This distinguished their work from other studies on the current Gulf wars, which were deficient in one or more ways: failure to perform in-depth diagnostic assessments; use of broad sampling that did not distinguish combat from support personnel; or assessment by snapshot rather than longitudinal follow-up. The Walter Reed team assessed over 18,000 army soldiers in infantry brigade combat teams at three points: pre-deployment (to establish a baseline); three months after deployment; and at twelve months post-deployment. After three months the rate of PTSD (symptoms accompanied by "serious impairment") was 6.3 percent higher than the pre-deployment baseline. At a year, it was 7.3 percent higher.

The New VA Rule
On July 12, 2010, General Shinseki penned an op-ed in USA Today ("For Vets with PTSD, End of an Unfair Process") announcing a new Veterans Administration rule making it easier for veterans suffering from PTSD to file disability claims. Part of the rule was straightforward: The VA would no longer require that a veteran provide documentation of his exposure to combat trauma, seeing how such paperwork is often very difficult for veterans to obtain. Streamlining the lumbering claims bureaucracy is one thing, and welcome it is, but the new rule does not end there. It also establishes that noninfantry personnel can qualify for PTSD disability if they had good reason to fear danger, such as firefights or explosions, even if they did not actually experience it. "[If] a stressor claimed by a veteran is related to the veteran's fear of hostile military or terrorist activity, he is eligible for a PTSD benefits," according to the Federal Register. This is a strikingly novel amendment. The idea that one can sustain an enduring and disabling mental disorder based on anxious anticipation of a traumatic event that never materialized is a radical departure from the clinical--and common-sense--understanding that traumatic stress disorders are caused by events that actually do happen to people.[1] However, this is by no means the first time that controversy and ambiguity have swirled around the diagnosis of PTSD.

During the Civil War, some soldiers were said to suffer "irritable heart" or "Da Costa's Syndrome"--a condition marked by shortness of breath, chest discomfort, and pounding palpitations that doctors could not attribute to a medical cause. In World War I, the condition became known as "shell shock" and was characterized as a mental problem. The inability to cope was believed to reflect personal weakness--an underlying genetic or psychological vulnerability; combat itself, no matter how intense, was deemed little more than a precipitating factor. Otherwise well-adjusted individuals were believed to be at small risk of suffering more than a transient stress reaction once they were removed from the front.

In 1917, the British neuroanatomist Grafton Elliot Smith and the psychologist Tom Pear challenged this view. They attributed the cause more to the experiences of war and less to the character or fiber of soldiers themselves. "Psychoneurosis may be produced in almost anyone if only his environment be made 'difficult' enough for him," they wrote in their book, Shell Shock and Its Lessons. This triggered a feisty debate within British military psychiatry, and eventually the two sides came to agree that both the soldier's predisposition to stress and his exposure to hostilities contributed to breakdown. By World War II, then, military psychiatrists believed that even the bravest and fittest soldier could endure only so much. "Every man has his breaking point," the saying went.

The story of PTSD, as we know it today, starts with the Vietnam War. In the late 1960s, a band of self-described antiwar psychiatrists--led by Chaim Shatan and Robert Jay Lifton, who was well known for his work on the psychological damage wrought by Hiroshima--formulated a new diagnostic concept to describe the psychological wounds that the veterans sustained in the war. They called it "Post-Vietnam Syndrome," a disorder marked by "growing apathy, cynicism, alienation, depression, mistrust, and expectation of betrayal as well as an inability to concentrate, insomnia, nightmares, restlessness, uprootedness, and impatience with almost any job or course of study." Not uncommonly, the psychiatrists said, these symptoms did not emerge until months or years after the veterans returned home. Civilian contempt for veterans, according to Messrs. Shatan and Lifton, further entrenched their hostility and impeded their return.
This vision inspired portrayals of the Vietnam veteran as a kind of "walking time bomb," "living wreckage," or rampaging loner, images immortalized in films such as "Taxi Driver" and "Rambo." In the summer of 1972, the New York Times ran a front-page story on Post-Vietnam Syndrome. It reported that 50 percent of all Vietnam veterans--not just combat veterans--needed professional help to readjust, and contained phrases such as "psychiatric casualty," "emotionally disturbed," and "men with damaged brains." By contrast, veterans of World War II were heralded as heroes. They had fought in a popular war, a vital distinction for understanding how veterans and the public give meaning to their wartime hardships and sacrifice.

Historians and sociologists note that the high-profile involvement of civilian psychiatrists in the wake of the Vietnam War was another feature that set those returning soldiers apart. "The suggestion or outright assertion was that Vietnam veterans have been unique in American history for their psychiatric problems," writes the historian Eric T. Dean Jr. in Shook over Hell: Post-Traumatic Stress, Vietnam, and the Civil War. As the image of the psychologically injured veteran took root in the national conscience, the psychiatric profession debated the wisdom of giving him his own diagnosis.
PTSD Becomes Official

In 1980, the American Psychiatric Association adopted post-traumatic stress disorder (rather than the narrower post-Vietnam syndrome) as an official diagnosis in the third edition of its Diagnostic and Statistical Manual. A patient could be diagnosed with PTSD if he experienced a trauma or "stressor" that, as DSM described it, would "evoke significant symptoms of distress in almost everyone." Rape, combat, torture, and fires were those deemed to fall, as the DSM III required, "generally outside the range of usual human experience." Thus, while the stress was unusual, the development of PTSD in its wake was not.

No longer were prolonged traumatic reactions viewed as a reflection of an individual's constitutional vulnerability. Instead, stress-induced syndromes were a natural process of adapting to extreme stress. With the introduction of PTSD into the psychiatric manual, the single-minded emphasis on the importance of one's pre-morbid state in shaping response to crisis gave way to preoccupation with the trauma itself and its supposed leveling effect on human response. Surely, it was wrong of earlier psychiatrists to attribute war-related pathology solely to the combatant himself, but the DSM III definition embodied an equal but opposite error: It obliterated the role of an individual's own characteristics in the development of the condition. Not surprising, perhaps, this blunder served a political purpose. As British psychiatrist Derek Summerfield put it, the newly minted diagnosis of PTSD "was meant to shift the focus of attention from the details of a soldier's background and psyche to the fundamentally traumatic nature of war."

Shatan and Lifton clearly saw PTSD as a normal response. "The placement of post-traumatic stress disorder in [the DSM] allows us to see the policies of diagnosis and disease in an especially clear light," writes combat veteran and
sociologist Wilbur Scott in his detailed 1993 account The Politics of Readjustment: Vietnam Veterans Since the War. The diagnosis of PTSD is in the DSM, Mr. Scott writes, "because a core of psychiatrists and Vietnam veterans worked conscientiously and deliberately for years to put it there . . . at issue was the question of what constitutes a normal reaction or experience of soldiers to combat." Thus, by the time PTSD was incorporated into the official psychiatric lexicon, it bore a hybrid legacy--part political artifact of the antiwar movement, part legitimate diagnosis.

Over the years, the major symptoms of PTSD have remained fairly straightforward--re-experiencing, anxiety, and phobic avoidance--but what counted as a traumatic experience turned out to be a moving target in subsequent editions of the DSM. In 1987, the DSM III was revised to expand the definition of a traumatic experience. The concept of stressor now included witnessing harm to others, such as a horrific car accident in progress. In the fourth edition in 1994, the range of "traumatic" events was expanded further to include hearing about harm or threats to others, such as the unexpected death of a loved one or receiving a fatal diagnosis such as terminal cancer oneself. No longer did one need to experience a life-threatening situation directly or be a close witness to a ghastly accident or atrocity. As long as one experienced an "intense fear, helplessness, or horror" in response to a catastrophic event (e.g., after watching the September 11 terrorist attacks on television, or being in a minor car accident) he could conceivably qualify for a diagnosis of PTSD if symptoms of re-experiencing, arousal, and phobias persisted for a month.

There is pitched debate within the field of traumatology as to whether a stressor should be defined as whatever traumatizes a person. True, a person might feel "traumatized" by, say, a minor car accident--but to say that a fender-bender counts as trauma alongside such horrors as concentration camps, rape, or the Bataan Death March is to dilute the concept. "A great deal rides on how we define the concept of traumatic stressor," says Richard J. McNally. In the civilian realm, he says, "the more we broaden the category of traumatic stressors, the less credibly we can assign causal significance to a given stressor itself and the more weight we must place on personal vulnerability." In the context of war, too, while anticipatory fear of being thrust in harm's way could conceivably morph into a crippling stress reaction, this will almost surely be more likely among individuals who struggled with anxiety-related problems prior to deployment. Surely, their distress merits treatment from military psychiatrists, but the odds that such symptoms persist after separation from the military, let alone harden into a serious, lasting state of disablement, are probably very low.

The Troubled VA Disability System
Secretary Shinseki's move to reduce the bureaucratic hurdles to the VA disability system and broaden eligibility for PTSD will add to the already accelerating stream of veterans who are applying to enter it. Thus, it is imperative that the VA turn its attention to that system itself. Two overarching problems need remedies. The first is the culture of clinical diagnosis. Some disability evaluators now use a detailed interview checklist to gauge the degree to which daily function is impaired, but its implementation is uneven across medical centers. Thus, it is still easy for clinicians--especially those whose diagnostic skills were honed during the Vietnam era--to label problems such as anxiety, guilt over comrades who died, and chronic sleep disturbance mental illnesses. This is facile, of course, as symptoms splay out along a continuum ranging from normal, if painful, readjustment difficulties to chronic, debilitating pathology. Further, not all symptoms of distress in someone who has been to war reflexively signal the presence of PTSD, as some clinicians seem to think. Among veterans whose problems are indeed war-related, however, the distinction between reversible and lasting incapacitation matters greatly when the veteran is seeking disability status. And this brings us to the second matter: the inadvertent damage that disability benefits themselves can sometimes cause.

Imagine a young soldier wounded in Afghanistan. His physical injuries heal, but his mind remains tormented. Sudden noises make him jump out of his skin. He is flooded with memories of a bloody firefight, tormented by nightmares, can barely concentrate, and feels emotionally detached from everything and everybody. At 23 years old, the soldier is about to be discharged from the military. Fearing he'll never be able to hold a job or fully function in society he applies for "total" disability (the maximum designation, which provides roughly $2,300 per month) compensation for PTSD from the VA. This soldier has resigned himself to a life of chronic mental illness. On its face, this seems only logical, and granting the benefits seems humane. But in reality it is probably the last thing the young soldier-turning-veteran needs--because compensation will confirm his fears that he is indeed beyond recovery.
traumatic stress disorder, or other anxiety disorders stemming from military activity would be eligible for a financial incentive (which Burr called a "wellness stipend") to adhere to an individualized course of treatment and agree to a pause in claims action for at least a year or until completion of treatment, which ever came first. The bill died in committee.

Don't Fight the Same War Twice
Mental health experts have learned a lot about how not to treat veterans from our experience during the Vietnam era. I speak from my experience as a psychiatrist at the West Haven Veterans Affairs Medical Center in Connecticut from 1988 to 1992, a time of blossoming interest in PTSD within both the VA and the mental-health establishment. Good intentions were abundant, but, in retrospect, much of our treatment philosophy was misguided. For example, clinicians tended to view whatever problem beset a veteran as a product of his war experience. In addition, therapists spent too much time urging veterans to experience catharsis by reliving their war experiences in group therapy, individual therapy, art therapy, and theatre reenactments. Groups of twenty or so veterans were admitted to the hospital and stayed together, platoonlike, for four months. This practice took them out of their communities and away from their families. I remember some of the men coming back from a day's leave from the hospital ward with new war-themed tattoos and combat fatigues--not exactly readjustment! It is clear, in retrospect, that instead of fostering regression, we should have emphasized resolution of everyday problems of living, such as family chaos, employment difficulties, and substance abuse.

The good news is that most of these inpatient programs are now shuttered. Studies showed them to be largely ineffective. What followed over the years was a wholesale shift away from cathartic reenactment of war trauma and a growing emphasis on forward-looking rehabilitation and evidence-based treatments such as cognitive therapy, behavioral desensitization (some techniques involving virtual reality recreations of combat scenarios), and medication if needed. The VA does appear to be making serious efforts to ensure that all mental health clinics are equipped to offer state of the art treatment for PTSD.
Some clinicians, myself included, would even like to see the diagnosis of PTSD downplayed altogether in favor of trying to understand patients' symptoms in context. As Texas psychiatrist Martha Leatherman puts it, "behaviors such as easy startling, hypervigilance, and sleep disturbance that are common in combat situations are normal, survival mechanisms," she says. Unfortunately, when they return, veterans are told that these symptoms mean PTSD. "This stirs up visions of Vietnam veterans living under bridges," Leatherman says, "and then, in a panic, they apply for disability compensation for PTSD so that they won't end up homeless too."

Regrettably, the legacy of Vietnam era PTSD haunts the current generation of veterans. "It has been very troubling to me to see OEF/OIF veterans who truly need mental health treatment refuse it because it would mean having an illness that is associated with Vietnam-era chronicity and thus is incurable." The clinicians' job, of course, is not to incite morbid preoccupations, but to dispel misconceptions about Vietnam veterans (the vast majority of whom went on to function well) and steer veterans, as early as possible, to healthier interpretations of their symptoms. Early intervention also leverages the well-established fact that prognosis after trauma greatly depends on what happens to the individual in its

While a sad verdict for anyone, it is especially tragic for someone only in his twenties. Injured soldiers can apply for and receive VA disability benefits even before they have been discharged from the military--and, remarkably, before they have even been given the psychiatric treatment that could help them considerably. Imagine telling someone with a spinal injury that he'll never walk again--before he has had surgery and physical therapy. A rush to judgment about the prognosis of psychic injuries carries serious long-term consequences insofar as a veteran who is unwittingly encouraged to see himself as beyond repair risks fulfilling that prophecy. Why should I bother with treatment? he might think. A terrible mistake, of course. The months before and after separation from the service are periods when mental wounds are fresh and thus most responsive to therapeutic intervention, including medication.

Told he is disabled, the veteran and his family may assume--often incorrectly--that he is no longer able to work. At home on disability, he risks adopting a "sick role" that ends up depriving him of the estimable therapeutic value of work. Lost are the sense of purpose work gives (or at least the distraction from depressive rumination it provides), the daily structure it affords, and the opportunity for socializing and cultivating friendships. The longer he is unemployed, the more his confidence in his ability and motivation to work erodes and his skills atrophy. Once a patient is caught in such a downward spiral of invalidism, it can be hard to throttle back out. What's more, compensation contingent upon being sick often creates a perverse incentive to remain sick. For example, even if a veteran wants very much to work, he understandably fears losing his financial safety net if he leaves the disability rolls to take a job that ends up proving too much for him. This is how full disability status can undermine the possibility of recovery.

What To Do: Treatment First
For many veterans, the transition between military and civilian life is a critical juncture marked by acute feelings of flux and dislocation. Recall the scene in The Hurt Locker (one of the few scenes, incidentally, that former soldiers have deemed realistic) in which Sergeant William James stares at the wall of cereal boxes in the supermarket, disoriented by the tranquil and often trivial nature of the civilian world. As Sebastian Junger wrote in his powerful book War, "Some of the men worry they'll never again be satisfied with a 'normal life' . . . They worry that they may have been ruined for anything else."

Returning from war is a major existential project. Imparting meaning to the wartime experience, reconfiguring personal identity, and reimagining one's future take time. Sometimes the emotional intensity can be overwhelming--especially when coupled with nightmares and high anxiety or depression--and even warrants professional help. When this happens, the veteran should receive a message of promise and hope. This means a prescription for quality treatment and rehabilitation--ideally before the patient is even permitted to apply for disability status. However, under the current system, when a veteran files a disability claim, a ratings examiner is assigned to determine the extent of incapacitation, irrespective of whether he has first received care.

As part of the assessment, the examiner requests a psychiatric evaluation with a psychiatrist or a psychologist to obtain a diagnosis. If the veteran is diagnosed with PTSD by the clinician, the ratings examiner then assigns a severity index to his disability. The Veterans Benefits Administration recognizes different levels of disability. As detailed in the Code of Federal Regulations, a ten percent severity rating for a mental illness denotes "mild or transient symptoms which [affect] occupational tasks only during periods of significant stress." A patient assigned 30 percent disability has "intermittent periods of inability to perform occupational tasks although generally functioning satisfactorily." A 50 percent rating begins to denote significant deficits including "difficulty in understanding complex commands" and reduced reliability and productivity. The most severe level, 100 percent, corresponds to "total occupational and social impairment."

Something is terribly wrong with this picture. To conclude that a veteran has dismal prospects for meaningful recovery before he or she has had a course of therapy and rehabilitation is premature in the extreme.[2] To be sure, the VA is trying hard to make treatment accessible, but administrators, raters, and clinicians cannot require patients to accept it as a condition of being considered for disability compensation. Absent a course of quality treatment and rehabilitation, evaluators simply do not have enough evidence to make a determination. Unwittingly, this policy has set in motion a growing dependence on the VA and disincentive to meaningful improvement. In 2008, former Senator Richard Burr of North Carolina, then the ranking member of the Senate Veterans Affairs Committee, sought a limited remedy. He introduced the Veterans Mental Health Treatment First Act. The purpose of this bill was to induce new veterans to embark upon a path to recovery. Any veteran diagnosed with major depression, post-immediate wake. That is why serious attention must be paid to the everyday problems that beset many veterans during the readjustment period, such as financial stress, marital discord, parenting strains, occupational needs.[3]
Finally, the balkanization of the veteran's services complex demands attention. The federal Veterans Benefits Administration (VBA) and the Veterans Health Administration (VHA) tend to operate in separate universes.

The VBA is geared toward helping veterans maximize benefits and gives little to no attention to improving their clinical situation. On the other hand, the VHA is focused on treatment, as it should be, but doesn't extend its expertise to helping veterans with the financial hardships they face. (These can be the kinds of problems that might lead a patient to turn to disability compensation--not because he is incapable of work but because the reliable check is a rational solution to his financial woes.) County-based Veterans Service Officers actively help veterans file for disability--not necessarily a bad thing at all, but because they are advocates, their job is to get a veteran what he wants, which is not necessarily in his best clinical interest. Lastly, the Veteran Service Organizations which, as a matter of principle, are driven to funnel largesse to their constituents, tend to be extremely suspicious of proposed reforms of the disability system, as they were of Senator Burr's proposal. With the missions of both agencies and the agendas of pressure groups all working at cross purposes, disability reform is a daunting challenge indeed.

Anyone who fights in a war is changed by it, but few are irreparably damaged. For those who never regain their civilian footing despite the best treatment, full and generous disability compensation is their due. Otherwise, it is reckless to allow a young veteran to surrender to his psychological wounds without first urging him to pursue recovery.
Over the last hundred years or so, psychiatry has taken very different perspectives on war stress: from an overly harsh, blame-the-soldier stance in World War I, to the healthy recognition in World War II that even the most psychologically healthy individual can develop war-related symptoms, to the misguided expectation in the wake of Vietnam that lasting PTSD was routine. The new VA rule, which expands PTSD disability eligibility to noncombatants who have experienced the dread of harm but have not had an actual encounter with it, alters the meaning yet again. What should have been a welcome bureaucratic reform by the VA--waiving documentation that might be difficult or impossible to obtain--ended up distorting the diagnosis. Add to this the practice of conferring disability status upon a veteran before his prospects for recovery are known, and the long journey home will now be harder than it already is.
[Source: American Enterprise Institute for Public Policy Research Sally Satel article 1 Feb 2011 (Sally Satel, M.D., is a resident scholar at AEI) ]

Mental Health Stability in Veterans with Post-traumatic Stress Disorder Receiving Varenicline

Austin R. Campbell, Pharm.D.; Keith D. Anderson, Pharm.D., BCPP

Posted: 11/23/2010; American Journal of Health-System Pharmacy. 2010;67(21):1832-1837. 2010 American Society of Health-System Pharmacists, Inc.
Abstract and Introduction
Abstract

Purpose. The effects of varenicline treatment for smoking cessation on mental health (MH) stability in veterans with posttraumatic stress disorder (PTSD) was studied.
Methods. Data were collected by retrospective chart review at a Veterans Affairs medical center. Patients with PTSD who were prescribed varenicline for smoking cessation between May 2006 and July 2008 were included; all patients had failed previous attempts to quit using nicotine replacement therapy, bupropion, or both. The average numbers of encounters per month with MH professionals in a six-month baseline period before varenicline, during treatment, and after treatment were compared. The numbers of MH encounters were compared for patients with multiple MH disorders including major depressive disorder, schizophrenia, or bipolar disorder and those with PTSD alone. Patients who had completed a full course of varenicline therapy (412 weeks) without MH decompensation were surveyed to determine the rate of smoking cessation.
Results. Data were analyzed for 78 patients. MH encounters during varenicline therapy increased 29% over baseline. There was no significant difference in the numbers of encounters in the baseline and postvarenicline periods. MH decompensations were documented for 4 patients during varenicline therapy and 2 after completion of therapy. Before, during, and after varenicline, patients with multiple MH disorders had significantly more MH encounters than those with PTSD alone. Of the 42 patients in the follow-up survey, 19 (45%) said they refrained from smoking for 30 days and 13 (31%) for 90 days.
Conclusion. Varenicline appeared to have destabilizing effects on MH in veterans with PTSD.
Introduction

Posttraumatic stress disorder (PTSD) is a chronic anxiety disorder of increasing concern among the veteran population. Like most mental health (MH) disorders, PTSD has demonstrated a strong correlation with tobacco dependence. An estimated 4086% of this population is considered tobacco dependent.[13] Numerous studies have shown that patients with MH disorders have significantly higher rates of smoking than the general population.[18] This circumstance is made worse by the fact that only 1026% of MH patients are able to achieve prolonged smoking cessation, a rate less than half that for the general population.[48] Considering the detrimental health effects associated with smoking, newer and more effective treatments for tobacco dependence need to be explored in this population.

Varenicline, a novel medication for the treatment of tobacco dependence, was approved for marketing by the Food and Drug Administration (FDA) in May 2006. Its unique mechanism of action decreases mesolimbic dopamine release through partial agonism of the 42 nicotinic acetylcholine receptor, which reduces nicotine cravings and positive reinforcement of smoking.[9,10] Early clinical trials with varenicline reported smoking cessation rates greater than 40% in patients receiving 12 weeks of therapy.[1115] Further studies have shown varenicline to be more effective than bupropion or the transdermal nicotine patch and equally effective as combination therapy.[1621] The most common adverse effects recorded in these trials were nausea, headache, insomnia, and abnormal dreams. Varenicline is still considered first-line therapy in the treatment of tobacco dependence, despite numerous postmarketing case reports associating the drug with serious neuropsychiatric adverse effects.[2227] FDA safety information has been added to varenicline's labeling, warning of the medication's potential to cause agitation, hostility, depressed mood, changes in behavior or thinking, suicidal ideation, and suicidal behavior.

The prevalence of and risk factors for the neuropsychiatric symptoms associated with varenicline have yet to be determined in clinical trials. Safety data on varenicline have indicated no definitive mechanism of action for these effects and are largely derived from the available case reports, which have all involved patients with MH disorders.[2327] Initial clinical trials of varenicline excluded patients suffering from psychiatric conditions. To date, only two studies have evaluated the safety of varenicline in this population. Stapleton et al.[28] compared varenicline with nicotine replacement therapy in a population that included 111 patients with mental illness. The results indicated no difference in the frequency of adverse effects experienced by patients with mental illness versus those without. Purvis et al.[29] evaluated the safety and effectiveness of varenicline in a population including 24 MH patients at a Veterans Affairs medical center (VAMC). The prevalence of underlying mental illness in patients who successfully quit smoking (4 of 15, 27%) was significantly lower than in patients who were not successful (20 of 35, 57%) (p < 0.001). In addition, 13 patients (26%) dropped out because of adverse effects, 4 of whom experienced aggression, agitation, mood changes, or major depressive state.

Currently, there is no evidence to support the use of varenicline in patients suffering from PTSD. Given this population's high prevalence of tobacco dependence and low cessation rates, alternative therapies need to be explored. The primary objective of this study was to determine the effects of varenicline on MH stability in a veteran population suffering from PTSD. This study also investigated whether patients suffering from axis I MH disorders (e.g., major depressive disorders, schizophrenia, bipolar disorder)[30] in addition to PTSD are more susceptible to the neuropsychiatric adverse effects of varenicline. In addition, the sustained smoking cessation rate after treatment with varenicline in this population was investigated.
Methods
Design

This was a retrospective cohort study conducted at a single VAMC in Kansas City , Missouri , in patients with a diagnosis of PTSD receiving smoking cessation therapy with varenicline between May 2006 and July 2008. The study received approval from the facility's institutional review board and was conducted in two phases: (1) a retrospective chart review comparing the average number of MH encounters required by patients before, during, and after treatment with varenicline and (2) a follow-up telephone survey of all patients completing a full 412-week course of varenicline without a decompensation in their MH stability to determine the rate of smoking cessation. For both phases, data were extracted through use of the computerized patient record system (CPRS).

For the first phase of the study, the number of MH encounters per month was collected for all patients beginning six months before starting varenicline and continuing for three months after varenicline discontinuation. The study defined a MH encounter as any documented interaction, either in person or by telephone, between a patient and a provider for the treatment or follow-up of an axis I MH disorder. The providers included psychiatrists, psychologists, and nurse practitioners working in the MH department. Any MH encounter specifically related to smoking cessation therapy for a patient was excluded from evaluation. Information was divided into three time periods for comparison. The first period included all MH-encounter data for the six months prior to treatment with varenicline; this information was used to establish a baseline for MH encounters. The second period consisted of MH-encounter data for patients actively receiving treatment with varenicline. Data gathered for this period would be compared with the baseline data. This period extended from the date varenicline was issued to five days after the last expected dose of medication; the additional five days allowed for washout of varenicline. Unless otherwise documented in the CPRS, patients filling a prescription for varenicline were assumed, for the purposes of this study, to have taken a full 4 weeks of medication. Patients ordering one or two refills were assumed to have taken varenicline for 8 or 12 weeks, respectively. The third, and final, period included MH-encounter data for the three months after the medication washout. Data gathered for this period would be compared with baseline to determine any prolonged neuropsychiatric effects of varenicline. Patient data in all three periods were also evaluated for concomitant axis I MH disorders. This information was used to further divide the study population into two groups: (1) patients diagnosed with PTSD and a concomitant axis I MH disorder and (2) patients with a diagnosis of PTSD only. The data for the two groups would be compared.

Finally, a follow-up telephone survey of patients who successfully completed a full course of varenicline therapy (412 weeks) without an acute decompensation in MH stability warranting early termination of the drug was conducted. All patients were surveyed in April 2009. An automated messaging system with touch-tone answering capabilities was used for the survey. After listening to a brief consent statement, patients were given the option to participate or decline the survey. Patients agreeing to take part in the survey were asked a series of yes-or-no questions regarding their smoking cessation therapy with varenicline. The purpose of the survey was to determine the effectiveness of varenicline for initial and sustained smoking cessation in the study population.
Patients

Patients included in the study were 18 years of age or older with a diagnosis code for PTSD as specified in the Diagnostic and Statistical Manual of Mental Disorders.[30] In order to receive varenicline, patients needed to have at least one previous smoking cessation failure using nicotine replacement therapy, bupropion, or both. Patients were required to have a minimum of one MH encounter per year for treatment or monitoring of PTSD. A MH encounter was considered to be any outpatient or telephone contact with a provider for which the primary or secondary reason was reported as PTSD, schizophrenia, major depressive disorder, or bipolar disorder. Patients were excluded from the study if they experienced a decompensation in MH stability or MH-related hospitalization in the 12 weeks prior to initiating varenicline. Decompensations in MH stability were defined as increased presence of auditory or visual hallucinations; paranoid delusions; suicidal or homicidal ideation; or manic, hypomanic, depressive, or major depressive episodes. MH hospitalizations were any emergency department or inpatient hospitalization in which the primary or secondary reason for admission was related to a decompensation in MH stability. In addition, patients receiving prescriptions for varenicline or being followed for their MH disorders at an outside facility were excluded. Any patient completing a full 412-week course of varenicline without a reported decompensation in MH stability was eligible for the follow-up telephone survey.
Outcome Measures

The primary outcome measure for this study was the average number of MH encounters per month required by patients while taking varenicline. Secondary outcome measures included (1) the number of MH hospitalizations or decompensations experienced by patients while taking varenicline, (2) the average number of MH encounters per month for patients with multiple axis I MH disorders compared with encounters for patients with PTSD alone, and (3) sustained smoking cessation rates at one and three months after completion of varenicline.
Statistical Analysis

To eliminate interrater variability, study charts were reviewed by a single investigator. Data for the primary outcome measure was analyzed using a one-tailed paired Student's t test comparing the average number of MH encounters per month in the baseline and varenicline treatment periods. The same statistical method was used to compare the postvarenicline period with the baseline. A t test was also used in comparing data for patients with multiple axis I MH disorders and patients with PTSD only. For all data analyzed, the a priori level of significance was 0.05.
Results
MH Stability

A total of 87 patients met initial criteria for the study. Nine patients were excluded because of provider-documented decompensation of their MH stability or MH hospitalization within 12 weeks of initiating varenicline. This resulted in 78 patients for inclusion in the final data analysis of the primary efficacy measure. These patients were principally Caucasian men with an average age of 55 years (Table 1). Compared with the baseline period, the mean S.D. number of MH encounters per month increased by 29% during the varenicline treatment period (0.84 0.54 and 1.08 0.77 encounters per month, respectively; p = 0.005). However, no difference in the number of encounters was seen between the postvarenicline period and the baseline (0.84 0.54 and 0.82 0.73 encounter per month, respectively; p = 0.4).


Overall, six patients experienced provider-documented decompensations in MH stability during either the varenicline treatment period or the postvarenicline period. Two of these patients reported suicidal ideation within the first 2 weeks of taking varenicline. One patient was taken to a local emergency department for observation, and the other was monitored on an outpatient basis. In both cases, varenicline was not documented by the MH provider as a potential contributor to the suicidal ideation, and the medication was continued. Two additional patients were hospitalized for MH-related reasons other than suicidal ideation after completion of varenicline. One of them was hospitalized at the end of the medication washout period, and the other nearly 10 weeks after varenicline was discontinued. Again, varenicline was not documented as a potential contributor to either hospitalization. In two separate instances, patients experienced depressive episodes shortly after initiating treatment with varenicline. In both cases, the cause of the episodes was attributed by providers to varenicline and the medication was promptly discontinued. Neither patient required hospitalization.

Of the 78 patients included in the final data analysis, 55% (n = 43) had a concomitant axis I MH disorder, the most common of which was major depressive disorder (n = 33, Table 1). When compared with patients with a MH diagnosis of PTSD alone (n = 35), those with multiple MH disorders required significantly more encounters per month during the baseline, varenicline treatment, and postvarenicline study periods (Table 2).


A total of 72 patients were eligible for the follow-up telephone survey after exclusion of any patients experiencing MH decompensations or MH hospitalizations. Of these, only 42 (58%) gave informed consent and participated in the telephone survey. Nineteen of these patients (45%) reportedly were able to refrain from smoking tobacco products for 30 days after completing treatment with varenicline. Overall, 13 surveyed patients (31%) reported complete abstinence from smoking for 90 days after completing treatment with varenicline (Table 3).

Discussion

The results of this study suggest that patients diagnosed with PTSD require significantly more MH-related encounters while taking varenicline for smoking cessation therapy. Compared with the baseline period, there was nearly a 30% increase in MH encounters during varenicline therapy. This marked increase suggests that varenicline had some destabilizing effects in this study population. Almost as noteworthy is the finding of no difference between the baseline and postvarenicline periods. The nearly identical MH encounter requirement in these two periods further implies that varenicline may cause some degree of MH instability. The apparent return to baseline of MH encounters after treatment with varenicline was discontinued also demonstrates a lack of persistent destabilization.

Also, during this study serious adverse effects, including suicidal ideation, occurred in 6 of 78 patients (8%). This rate is consistent with the findings of Purvis et al.;[29] 8% of their study population experienced neuropsychiatric effects ranging from agitation and anxiety to a depressive episode in 1 individual. To date, serious adverse effects such as found in that study and this study have been documented only in case reports and not in other clinical trials.[2327] Thus, the actual rate at which patients may experience neuropsychiatric effects from varenicline has not been consistently elucidated in the literature.

Another important finding of this study was that patients with multiple axis I disorders required nearly double the number of MH encounters as patients with PTSD only. Although this finding was statistically significant, the lack of a control group containing patients without a MH history makes interpreting the clinical relevance difficult. Furthermore, since the argument can be made that having multiple MH disorders alone necessitates an increase in provider follow-up, this finding does not necessarily mean that this subpopulation is more susceptible to neuropsychiatric effects of varenicline. Although data for both the multiple axis I and PTSD only groups indicated that patients required more MH encounters during the varenicline treatment period, statistical testing to substantiate the significance was not included in the study protocol and thus was not performed.

The sustained smoking cessation rate at 90 days after treatment was 31% (n = 13) in this population as determined in the automated telephone survey. Although this is less than the roughly 40% cessation rates reported with varenicline in other clinical trials, several factors may account for this.[1115] Traditionally, the MH population is more difficult to treat in regard to smoking cessation, with long-term quit rates of only 1026% reported in the literature.[48] Another consideration is that patients in this study were required to have failed at least one previous smoking cessation attempt with nicotine replacement therapy, bupropion, or both, so they may have been more treatment refractory. It is also important to note that self-reported data on smoking cessation are greatly limited by patients' recall ability and personal biases.

This study had several major limitations related to its retrospective design. The first concerns establishing a causal relationship between varenicline and the primary outcome measure. The retrospective nature of this study required provider documentation to be relied on exclusively in attributing MH effects to varenicline; it also limited the ability to evaluate other possible causes of MH decompensation (e.g., psychosocial stressors) and the increased need for provider follow-up. Another major limitation concerns determining the actual length of treatment with varenicline. Unless directly documented by providers upon follow-up, the last dose of medication for each patient was assumed to occur at the end of a four-week course of treatment. This could skew the data if numerous patients discontinued therapy before completing the full varenicline prescription. One other limitation concerns the chart review method. Using a single reviewer eliminates the possibility of interrater variability, but it also introduces potential for bias. The use of multiple reviewers could have minimized this, but resources for that were not available at the time.

One other limitation of this study concerns patient follow-up by providers after initiation of a new medication. In response to reports of neuropsychiatric adverse effects with varenicline, the Veterans Health Administration has implemented a new policy regarding use of the medication. The policy mandates that patients with a psychiatric disorder be evaluated by a MH provider before initiation of smoking cessation therapy with varenicline. It also requires providers to follow up with newly initiated patients within 30 days to monitor for neuropsychiatric effects. However, this policy was introduced after the time period for this study (May 2006 through July 2008). In addition, any MH encounters specifically for follow-up of smoking cessation were excluded from the data. On the basis of individual chart review, the possibility of bias resulting from this exclusion appears to be minimal.
Conclusion

Varenicline appeared to have destabilizing effects on MH in veterans with PTSD.


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The assistance of Richard S. Schaefer, Pharm.D., BCPS, Kansas City Veterans Affairs Medical Center , is acknowledged.
The authors have declared no potential conflicts of interest.

American Journal of Health-System Pharmacy. 2010;67(21):1832-1837. 2010 American Society of Health-System Pharmacists, Inc.

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